International Journal of Health Policy and Management
Volume:10 Issue: 11, Nov 2021

The WHO-CHOICE (World Health Organization CHOosing Interventions that are Cost-Effective) approach is unique in the global health landscape, as it takes a “generalized” approach to cost-effectiveness analysis (CEA) that can be seen as a quantitative assessment of current and future efficiency within a health system. CEA is a critical contribution to the process of priority setting and decision-making in healthcare, contributing to deliberative dialogue processes to select services to be funded. WHO-CHOICE provides regional level estimates of cost-effectiveness, along with tools to support country level analyses. This series provides an update to the methodological approach used in WHO-CHOICE and presents updated cost-effectiveness estimates for 479 interventions. Five papers are presented, the first focusing on methodological updates, followed by three results papers on maternal, newborn and child health; HIV, tuberculosis and malaria; and non- communicable diseases and mental health. The final paper presents a set of example universal health coverage (UHC) benefit packages selected through only a value for money lens, showing that all disease areas have interventions which can fall on the efficiency frontier. Critical for all countries is institutionalizing decisionmaking processes. A UHC benefit package should not be static, as the countries needs and ability to pay change over time. Decisions will need to be continually revised and new interventions added to health benefit packages. This is a vital component of progressive realization, as the package is expanded over time. Developing an institutionalized process ensures this can be done consistently, fairly, and transparently, to ensure an equitable path to UHC.

The World Health Organization’s (WHO’s) Choosing Interventions that are Cost-Effective (CHOICE) programme has been a global leader in the field of economic evaluation, specifically cost-effectiveness analysis for almost 20 years. WHO-CHOICE takes a “generalized” approach to cost-effectiveness analysis that can be seen as a quantitative assessment of current and future efficiency within a health system. This supports priority setting processes, ensuring that health stewards know how to spend resources in order to achieve the highest health gain as one consideration in strategic planning. This approach is unique in the global health landscape. This paper provides an overview of the methodological approach, updates to analytic framework over the past 10 years, and the added value of the WHO-CHOICE approach in supporting decision makers as they aim to use limited health resources to achieve the Sustainable Development Goals (SDGs) by 2030.

This paper forms part of an update of the World Health Organization Choosing Interventions that are Cost-Effective (WHO-CHOICE) programmes. It provides an assessment of global health system performance during the first decade of the 21st century (2000-2010) with respect to allocative efficiency in HIV, tuberculosis (TB) and malaria control, thereby shining a spotlight on programme development and scale up in these Millennium Development Goal (MDG) priority areas; and examining the cost-effectiveness of selected best-practice interventions and intervention packages commonly in use during that period. 

Generalized cost-effectiveness analysis (GCEA) was used to determine the cost-effectiveness of the selected interventions. Impact modelling was performed using the OpenMalaria platform for malaria and using the Goals and TIME (TB Impact Model and Estimates) models in Spectrum for HIV and TB. All health system costs, regardless of payer, were included and reported in international dollars. Health outcomes are estimated and reported as the gain in healthy life years (HLYs) due to the specific intervention or combination. Analysis was restricted to eastern sub-Saharan Africa and Southeast Asia. 

At the reference year of 2010, commonly used interventions for HIV, TB and malaria were cost-effective, with cost-effectiveness ratios less than I$ 100/HLY saved for virtually all interventions included. HIV, TB and malaria prevention and treatment interventions are highly cost-effective and can be implemented through a phased approach to full coverage to achieve maximum health benefits and contribute to the progressive elimination of these diseases. 

During the first decade of the 21st century (2000-2010), the global community has done well overall for HIV, TB, and malaria programmes as regards both economic efficiency and programmatic selection criteria. The role of international assistance, financial and technical, arguably was critical to these successes. As the global community now tackles the challenge of universal health coverage, this analysis can reinforce commitment to Sustainable Development Goal targets but also the importance of continued focus on these critical programme areas.

World Health Organization Choosing Interventions that are Cost-Effective (WHO CHOICE) has been a programme of the WHO for 20 years. In this latest update, we present for the first time a cross programme analysis of the comparative cost-effectiveness of 479 intervention scenarios across 20 disease programmes and risk factors. 

This analysis follows the standard WHO CHOICE approach to generalized cost-effectiveness analysis applied to two regions, Eastern sub-Saharan Africa and Southeast Asia. The scope of the analysis is all interventions included in programme specific WHO CHOICE analyses, using WHO treatment guidelines for major disease areas as the foundation. Costs are measured in 2010 international dollars, and benefits modelled beginning in 2010, or the nearest year for which validated data was available, both for a period of 100 years. 

Across both regions included in the analysis, interventions span multiple orders of magnitude in terms of cost-effectiveness ratios. A health benefit package optimized through a value for money lens incorporates interventions responding to all of the main drivers of disease burden. Interventions delivered through first level clinical and nonclinical services represent the majority of the high impact cost-effective interventions. 

Cost-effectiveness is one important criterion when selecting health interventions for benefit packages to progress towards universal health coverage (UHC), but it is not the only criterion and all calculations should be adapted to the local context. To support country decision-makers, WHO CHOICE has developed a downloadable tool to support the development of data for this criterion.

Information on cost-effectiveness allows policy-makers to evaluate if they are using currently available resources effectively and efficiently. Our objective is to examine the cost-effectiveness of health interventions to improve maternal, newborn and child health (MNCH) outcomes, to provide global evidence relative to the context of two geographic regions. 

  We consider interventions across the life course from adolescence to pregnancy and for children up to 5 years old. Interventions included are those that fall within the areas of immunization, child healthcare, nutrition, reproductive health, and maternal/newborn health, and for which it is possible to model impact on MNCH mortality outcomes using the Lives Saved Tool (LiST). Generalized cost-effectiveness analysis (GCEA) was used to derive average cost-effectiveness ratios (ACERs) for individual interventions and combinations (packages). Costs were assessed from the health system perspective and reported in international dollars. Health outcomes were estimated and reported as the gain in healthy life years (HLYs) due to the specific intervention or combination. The model was run for 2 regions: Eastern sub-Saharan Africa (SSA-E) and South-East Asia (SEA).  

  The World Health Organization (WHO) recommended interventions to improve MNCH are generally considered cost-effective, with the majority of interventions demonstrating ACERs below I$100/HLY saved in the chosen settings (lowand middle-income countries [LMICs]). Best performing interventions are consistent across the two regions, and include family planning, neonatal resuscitation, management of pneumonia and neonatal infection, vitamin A supplementation, and measles vaccine. ACERs below I$100 can be found across all delivery platforms, from community to hospital level. The combination of interventions into packages (such as antenatal care) produces favorable ACERs.  

  Within each region there are interventions which represent very good value for money. There are opportunities to gear investments towards high-impact interventions and packages for MNCH outcomes. Cost-effectiveness tools can be used at national level to inform investment cases and overall priority setting processes.

Background  To determine the health system costs and health-related benefits of interventions for the prevention and control of non-communicable diseases (NCDs), including mental health disorders, for the purpose of identifying the most cost-effective intervention options in support of global normative guidance on the best-buy interventions for NCDs. In addition, tools are developed to allow country contextualisation of the analyses to support local priority setting exercises. Methods  This analysis follows the standard WHO-CHOICE (World Health Organization-Choosing Interventions that are Cost-Effective) approach to generalized cost-effectiveness analysis applied to two regions, Eastern sub-Saharan Africa and South-East Asia. The scope of the analysis is all NCD and mental health interventions included in WHO guidelines or guidance documents for which the health impact of the intervention is able to be identified and attributed. Costs are measured in 2010 international dollars, and benefits modelled beginning in 2010, both for a period of 100 years. Results  There are many interventions for NCD prevention and management that are highly cost-effective, generating one year of healthy life for less than Int. $100. These interventions include tobacco and alcohol control policies such as taxation, voluntary and legislative actions to reduce sodium intake, mass media campaigns for reducing physical activity, and treatment options for cardiovascular disease (CVD), cervical cancer and epilepsy. In addition a number of interventions fall just outside this range, including breast cancer, depression and chronic lung disease treatment. Conclusion  Interventions that represent good value for money, are technically feasible and are delivered for a low per-capita cost, are available to address the rapid rise in NCDs in low- and middle-income countries. This paper also describes a tool to support countries in developing NCD action plans.